A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions?

Ask the client to lie on her back and with her knees ﬂexed.

Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis.

Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus.

Observe the client's perineum for the passage of clots and the amount of bleeding.

Answer and Explanation

The Correct Answer is A, B, C, D

The correct answer is A, B, C, D.

The nurse should plan to perform the following actions in this order:
A.   Ask the client to lie on her back and with her knees ﬂexed.
B.   Position one hand around the top of the client’s fundus and one hand just above the client’s symphysis pubis.
C.   Rotate the upper hand to massage the client’s uterus while using slight downward pressure to compress the fundus.
D.   Observe the client’s perineum for the passage of clots and the amount of
bleeding.
Fundal massage is performed to stimulate uterine contractions and prevent
postpartum hemorrhage.

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Correct Answer is B

Explanation

A newborn who was exposed to cocaine in utero may exhibit a high-pitched cry as well as other symptoms such as irritability, tremors, and feeding difficulties.

Choice A is not an answer because hypotonicity is not a common ﬁnding in newborns exposed to cocaine in utero.

Choice C is not an answer because increased head circumference is not a common ﬁnding in newborns exposed to cocaine in utero.

Choice D is not an answer because decreased startle response is not a common ﬁnding in newborns exposed to cocaine in utero.

A. A newborn who is 24 hr old and has not had a meconium stool. B. A newborn who has a short frenulum and is having difficulty breastfeeding. C. A newborn who is 10 hr old and has onset tachypnea. D. A newborn who is 30 hr old and has blood-tinged discharge in her diaper.

Correct Answer is C

Explanation

A newborn who is 10 hr old and has onset tachypnea.
Tachypnea means rapid breathing and can be a sign of respiratory distress.
Transient tachypnea of the newborn (TTN) is a respiratory disorder usually seen shortly after delivery in babies who are born near or at term.
It is important for the nurse to assess this newborn ﬁrst to determine the cause of the tachypnea and provide appropriate care.

Choice A, a newborn who is 24 hr old and has not had a meconium stool, may
require further assessment but is not as urgent as a newborn with tachypnea.
Choice B, a newborn who has a short frenulum and is having difficulty breastfeeding, may require assistance with feeding but is not as urgent as a newborn with tachypnea.
Choice D, a newborn who is 30 hr old and has blood-tinged discharge in her diaper, may have pseudomenstruation which is normal and not a cause for concern.

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A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who was exposed to cocaine in utero. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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